Malaria and tuberculosis (TB) are two
infectious and potentially lethal diseases that
have greatly affected the Asian and Pacific
region. Progress has been made in fighting
these pandemics in the region, and the
number of malaria cases per 100,000
population has decreased significantly in
recent years. Nevertheless, there are still high
numbers of malaria cases in certain countries,
and progress in bringing these down has been
slow. There have been achievements in
reducing TB cases in the region, especially in
North and Central Asia, while the situation in
the Pacific is not so promising and deserves
attention.

The Asian and Pacific region has had
significant success in reducing the
incidence of malaria, placing several
countries on track to meet, or even
surpass, the malaria-related target of
Millennium Development Goal 6.

In 2011, the region recorded the lowest malaria
case incidence (136 per 100,000 population) in
over three decades. The incidence was below 200
for the first time since 2000 and was less than
half the figure for 2010, indicating a reduction
of more than 50 per cent in the space of one year.
Between 2001 and 2011, East and North-East
Asia experienced a dramatic fall of over 90 per
cent to very low levels of less than 2 per 100,000
population. In North and Central Asia, the
decline was even greater and to even lower levels.
Between 2001 and 2011, South and South-West
Asia experienced a large drop in incidence, from
429 to 127, while in South-East Asia the number
went from 765 to 349. Within the same period,
the incidence in the Pacific (excluding Australia
and New Zealand), albeit at much higher rates
than other subregions, also fell significantly,
dropping from 30,605 to 14,266.

Figure B.4-1 Malaria cases for 2001 and 2011, for the 10
countries that had the highest incidence in
2001

Several countries across the region have shown remarkable progress in combating malaria over the past decade and they are therefore on track to accomplish a diminution in the incidence of at least 75 per cent from 2000 to 2015,1 significantly greater than the relevant target under Millennium Development Goal 6. For example, Cambodia, the Lao People’s Democratic Republic and Sri Lanka2 had malaria incidence surpassing 1,000 per 100,000 in 2000, but, by 2011, the incidence of malaria in these countries had fallen by over one half to less than 500 per 100,000. These three countries also experienced substantial progress in decreasing the numbers of malaria cases. The 57,423 cases reported in Cambodia in 2011 constituted a 72 per cent decline from the figure for 2000. Over the same period, the cases reported in the Lao People’s Democratic Republic (17,904) and Sri Lanka (175) for 2011 showed declines of over 90 per cent from 2000.

Some countries in the Asian and Pacific
region, particularly those with tropical
or subtropical climates, continue to face
challenges in combating malaria.

As rainfall and warm temperatures present an
ideal habitat for Anopheles mosquitoes (the
mosquitoes that host the malaria parasite),
tropical and subtropical countries such as India
(24 per cent), Indonesia (24 per cent) and Papua
New Guinea (19 per cent) predictably reported the highest proportions of malaria cases in the
region in 2011. The situation in Indonesia
warrants attention since, between 2000 and
2011, the country experienced only an 8 per cent
decrease in case numbers, while the declines in
India and Papua New Guinea were each about
36 per cent. The decline in Papua New Guinea
has been significant; yet, in 2011, it still had a
considerably higher incidence of malaria (14,617
cases per 100,000 population) than all the other
countries in the Asian and Pacific region except
Solomon Islands. In comparison, Indonesia and
India recorded incidence figures of 542 and 107,
respectively. In addition to Papua New Guinea
and Solomon Islands, countries with a high
incidence of malaria are Timor-Leste (3,290) and
Vanuatu (2,384), both also surpassing the global
average (1,530). However, in 2011, the cases
recorded in Vanuatu represented a reduction of
about 67 per cent from the 2010 figure.

The number of annual malaria deaths in
the Asian and Pacific region has fallen
by over two thirds since 2000.

The region has seen a very sizable decline in the
number of malaria deaths, but, in some
countries, there is still a lack of data, and this
renders making comprehensive conclusions
difficult. Improvements in detection, treatment
and surveillance have proven to be instrumental
in reducing malaria deaths. The annual number
of malaria deaths in the region fell progressively
between 2000 and 2011, from 7,848 to 2,481,
which is the lowest number recorded since 1990.
Within the same period of time, the three
countries with the largest number of cases
showed some variations in patterns. India
witnessed the most deaths in 2006 (1,708), but
the number fell significantly to 753 in 2011.
Indonesia had a peak of 900 deaths in 2009 and
the number fell to 388 in 2011. Papua New
Guinea reported its highest number of deaths in
2005 (725), though the number declined steadily
to 431 within six years. Myanmar, another highendemic
country, also recorded a significant decline in deaths; the peak of 2,814 deaths
occurred in 2001 but the number then fell
steadily to 581 in 2011. However, this trend may
not be entirely representative given changes in
reporting practices.3

Figure B.4-2 Percentage change in malaria deaths between
2000 and 2011, for the six countries that had
the highest figures in 2000

The Asian and Pacific region as a whole
and most countries within it have met
the TB-related target of Millennium
Development Goal 6, but the region still
accounts for the largest population of
persons living with TB in the world.

Between 2000 and 2011, the number of new TB
cases per 100,000 population in the region
declined steadily by 17 per cent, falling from 167
to 139. Nonetheless, with the largest population
of all regions (60 per cent of the global
population), Asia and the Pacific has been
recording a relatively larger population of those
living with TB for the past decade. In 2011, the
region hosted 8.5 million people living with TB
(72 per cent of the global figure).Nonetheless, the
figure for Asia and the Pacific (over 12.195
million) accounted for 78 per cent of the total
global figure in 2000, showing a more rapid
decline than the global aggregate. In 2011, there
were three times more people living with TB in
the Asian and Pacific region than in Africa. Yet,
while there was a reduction of 30 per cent from
2000 to 2011 of people living with TB in this
region, in Africa there was a 4 per cent increase
over the same period.

North and Central Asia experienced the greatest
reduction in the incidence of TB between 2000
and 2011 (45 per cent), followed by East and
North-East Asia (28 per cent), South-East Asia
(13 per cent) and South and South-West Asia
(12 per cent). The Pacific, on the other hand, was
the only subregion that, at a rate of 3 per cent,
experienced an increase. In 2011, the incidence
levels (per 100,000 population) of all North and
Central Asian countries were below the region’s
average rate (139), except Tajikistan (193). The
2011 incidence in Kazakhstan (129), Azerbaijan
(113), Uzbekistan (101) and Turkmenistan (74)
had dropped by about 65 per cent, or more, as
in the case of Azerbaijan, at 83 per cent, since
2000.

Another key approach to tracking a country’s
progress in addressing TB is by using the case
detection rate under the internationally
recommended TB control strategy Directly
Observed Treatment Shortcourse (DOTS). In
2000, the DOTS case detection rate in the Asian
and Pacific region was 46 per cent, while the
global rate was 51 per cent. The most recent data
for DOTS case detection rates are from 2011,
and in that year the region’s rate was equal to the
global rate, at 71 per cent, showing greater
improvement in the region than across the globe.
Among the Asian and the Pacific subregions,
South and South-West Asia recorded the lowest
rate in 2011 (59 per cent), followed by the Pacific
(65 per cent), South-East Asia (71 per cent),
North and Central Asia (77 per cent), and East
and North-East Asia (91 per cent).

Despite progress in the region more
broadly, the number of people living
with TB in the Pacific is rising.

The Pacific has always recorded the smallest
number of people living with TB in the region
(0.5 per cent of the region’s total figure in 2011);
yet, the number of new TB cases between 2000
and 2011 increased by 22 per cent. A notable
resurgence of TB cases was seen in the Marshall
Islands, where the incidence increased
consistently to reach 536 cases per 100,000 in
2011, which is more than double the rate of
2000. In Kiribati, there was an increase from
372 in 2000 to a peak of 502 in 2006 and then
a fall to 356 in 2011. Tuvalu and the Federated
States of Micronesia, on the other hand, showed
declining patterns within the same period, as the
two countries experienced steady decreases
from rates of 357 to 228 and of 279 to 200,
respectively. Almost no change occurred in Papua
New Guinea from 2000 to 2011, with an annual
average of 351 per 100,000 population, a high
burden that is accompanied by related challenges,
as discussed in the box below.

Figure B.4-4
Tuberculosis incidence, Pacific subregion,
2000-2011

Conducting national prevalence surveys
has helped countries to combat TB.

At the country level, Cambodia exhibits what can
be achieved in a low-income, high-burden
country. Cambodia and China are the only
countries in the region that twice conducted
a national prevalence survey between 2000 and 2011.4 Cambodia conducted the surveys in
2002 and 2011 and within that period, the
country’s TB prevalence was nearly halved, from
1,511 to 817 cases per 100,000 population.
China demonstrated similar success by reporting
a 36 per cent reduction in TB prevalence between 2000 and 2010, the years in which it carried out
the surveys. These successes may prove that
surveys contribute significantly to enhancing the
evaluation of the impact of TB control and help
identify ways to improve the way in which TB
is treated.

With 14,749 new TB cases diagnosed in 2011,a Papua
New Guinea has become the country with the highest
TB burden in the Pacific, the only subregion where TB
incidence has increased in recent years. TB is a treatable
disease; yet, in 2011, the country’s TB-related deaths
were estimated at 3,700, almost 90 times greater than
those in Australia (42), a Pacific country with just under
one tenth of the number of new cases in 2011 (1,202)
of Papua New Guinea. This shows that treatment for
many TB cases in Papua New Guinea is inadequate or
unattainable. In addition, some cases have become drug
resistant, making treatment even more complex.

People who are diagnosed with TB should undergo
treatment that involves taking anti-TB drugs
(antibiotics) for at least six to nine months. However,
such a lengthy treatment period often makes individuals
prone to stopping the medication once they begin to feel
better. Such an interruption unfortunately enables the
bacteria to mutate, develop resistance and bring about
further infection. A shortage of drugs is another factor
that causes individuals to stop their medication.
Financial constraints and the poor management of stock
replenishment are frequent causes of shortages. Improper
treatment regimens can also cause drug resistance. A
clinical setting with poor quality of resources and the
behavioural patterns of those infected may therefore
increase the likelihood of drug-resistant TB.

Multi-drug-resistant TB (MDR-TB), in which the
disease is resistant to basic anti-TB drugs (isoniazid and
rifampicin), is a growing problem in Papua New Guinea.
In 2011, the country estimated 410 MDR-TB cases, or
4.9 per cent of total TB cases.b Treatment for MDR-TB
entails a different combination of stronger antibiotics for an even longer period of time; the current regimens
recommended by the World Health Organization
(WHO) last 20 months.c In 2012, a more severe form
of drug resistant TB, called extensively drug-resistant TB
(XDR-TB), was observed through six cases arising in
Papua New Guinea’s Western Province.d XDR-TB shows
resistance to two of the second-line drugs that are used
to treat MDR-TB (namely the injectable agent and any
one fluoroquinolone). This level of drug-resistant TB
also comes about as a result of inadequate or interrupted
treatment for MDR-TB; moreover, the treatments for
MDR-TB and XDR-TB are even less accessible since the
options for treatment are limited and expensive. In
addition, studies on effective treatment for XDR-TB are
yet to be carried out in large cohorts, and, thus, WHO
cannot recommend a routine use of the treatment’s
alternatives.

In neighbouring Australia, which recently set up the
Centre of Research Excellence in Tuberculosis Control
to stop the spread of TB and to reduce its impact in the
Asian and Pacific region, efforts have been directed at
helping Papua New Guinea combat TB. The two
Governments have been collaborating to establish better
surveillance, detection, diagnosis and treatment for TB
in Western Province. Under the partnership, the WHObased
six-point Stop TB Strategy has been adopted to
reduce the burden of TB by 2015 by ensuring that all
TB patients, including those with drug-resistant TB,
benefit from universal access to high-quality diagnosis
and patient-centred treatment. Attention to having
patients take the proper and full course of anti-TB drugs
at the right time over the full period of medication has
also become a key focus of the Stop TB Strategy in the
fight to prevent the development of drug resistance.

Malaria cases (number, per 100,000 population)
The number of new cases of malaria reported
(presumed and confirmed) in a given time period
expressed per 100,000 population. Aggregate
calculations: Sum of individual country values
(number); weighted averages using population
(WPP2012) as weight (per 100,000 population).
Missing data are not imputed.

Malaria deaths (number)
Deaths caused by malaria in a given time period.
Aggregate calculations: Sum of individual
country values. Missing data are not imputed.

TB prevalence and incidence rates (per
100,000 population)
Prevalence: TB prevalence refers to the number
of cases of TB (all forms) in a population at
a given point in time (sometimes referred to as
“point prevalence”). It is expressed as the number
of cases per 100,000 population. Estimates
include cases of TB in people with HIV.
Incidence: TB incidence is the estimated number
of new TB cases arising in one year per 100,000
population. All forms of TB are included,
as are cases of people with HIV. Aggregate
calculations: MDG aggregation and imputation
methods; weighted averages using population
(WPP2012) as weight.

TB detection rate under DOTS (percentage of
new TB cases)
The TB detection rate is the percentage of
estimated new infectious TB cases detected under
the internationally recommended TB control
strategy DOTS. The term “case detection” as
used here means that TB is diagnosed in a patient
and is reported within the national surveillance
system, and then to WHO. Aggregate
calculations: Weighted averages using the
number of TB cases per year (WHO Global
Health Observatory) as weight. Missing data are
not imputed.

Population living with TB (thousands)
Population living with TB refers to the number
of cases of TB (all forms) in a population at
a given point in time expressed in thousands.
This is calculated for only economic, regional and
subregional groupings. Aggregate calculations:
MDG aggregation and imputation methods; the
population for each economic, regional or
subregional grouping multiplied by the TB
prevalence rate, divided by 100,000.

New cases of TB (thousands)
New cases of TB refers to the estimated number
of new TB cases arising in one year expressed in
thousands. This is calculated for only economic,
regional and subregional groupings. Aggregate
calculations: MDG aggregation and imputation methods; the population for each economic,
regional or subregional grouping multiplied by
the TB incidence rate, divided by 100,000.

Source

Source of malaria data: WHO Global Malaria
Programme, WHO World Malaria Report 2012,
annexes (available from www.who.int/malaria/
publications/world_malaria_report_2012/en/).
The principal data sources are national malaria
control programmes in endemic countries.
Standardized data collection forms are sent to
each Government. Survey data (demographic and
health surveys, multiple indicator cluster surveys
and malaria indicator surveys) have been used to
complement data submitted by national malaria
control programmes. Data obtained: 4 June 2013 for malaria deaths, and 27 June 2013 for
malaria cases.

Source of TB data: Millennium Indicators
Database. Based on data from WHO. Annual
standardized data collection forms are distributed
to national TB control programmes or the
relevant public health authorities. National TB
control programmes that respond to WHO are
also asked to update information on earlier years.
As a result, case notification and treatment
outcome data of a given year may differ from
those published previously. Completed forms
are collected and reviewed by WHO country
offices, regional offices and headquarters. Data
obtained: 1 August 2013 except Tuberculosis
detection rate under DOTS obtained on 19
August 2013.